Provider Demographics
NPI:1376553792
Name:STEVENS, JESSICA (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6300 MAIN ST
Mailing Address - Street 2:WOUND CARE AND HYPERBARICS
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4037
Mailing Address - Country:US
Mailing Address - Phone:225-658-4110
Mailing Address - Fax:
Practice Address - Street 1:6300 MAIN ST
Practice Address - Street 2:WOUND CARE AND HYPERBARICS
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4037
Practice Address - Country:US
Practice Address - Phone:225-658-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12058R208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
71287Medicare UPIN
LA4E5667302Medicare ID - Type Unspecified